Patients are suicidal more often than expected

Poor quality of life often is factor

It's an unpleasant reality that hospice professionals sometimes encounter a patient or family members who ask them to assist in hastening the patient's death.

When this happens, hospice staff can use the situation as an opportunity to make the patient's care more meaningful, an expert suggests.

Sometimes end-of-life patients who have a diminished capacity to enjoy life will believe that it would be better to commit suicide then continue to decline, says Liz Arnold, PhD, an assistant professor in the Department of Psychiatry and Behavioral Medicine at Wake Forest University School of Medicine in Winston-Salem, NC. Arnold conducts research on the issue of suicidal hospice patients, and she's spoken about this topic at national conferences, including the 2007 National Hospice & Palliative Care Organization's (NHPCO's) conference.

Arnold's research about hospice patients who want to hasten their deaths is ongoing. "I've been working in this area for over 10 years, and we've learned a lot in the last 10 years, I think," she says. "Ten years ago, nobody was talking about any of these things, especially in hospice care."

Since Arnold is a former hospice social worker, her research has involved interviewing hospice social workers as well. "We surveyed hospice social workers in North Carolina and South Carolina and asked about cases where hospice patients had either considered assisted suicide or suicide,"1 she says. "We use the term 'hastening death' and asked about their experiences with patients and families."

Hospice professionals occasionally encounter patients or family members who will ask about hastening the patient's death, but it is not a common question, says Van Grinwis, RN, home care manager for CarePartners Hospice & Palliative Care Services of Asheville, NC. In the past two years, Grinwis has heard of about three situations involving such requests.

Obviously, the first thing hospice professionals have to explain to patients and caregivers is that they do not hasten death, Grinwis says. At CarePartners Hospice, patients who make such requests are referred to the medical director, she says. "He takes care of educating the patient and assessing the patient to see what his or her needs are," Grinwis explains. "He lets patients and their families know what the hospice can offer them."

Sometimes it's just a matter of providing patients with pain management, getting them comfortable, either at their home or in an inpatient facility, Grinwis says. "It depends on what it is that makes the patient want to end his or her life," she says. "So finding out what it is the starting point of deciding what you're going to do with them and how you're going to help them."

When these requests come from people who have not enrolled in hospice care and who misunderstand what hospice care is about, the answer could be more education. But there are times when these patients may not be enrolled or may not call again, Grinwis adds.

Counseling and suicide prevention are needed

Common strategies for dealing with suicidal hospice patients are to provide counseling and suicide prevention, Arnold says.

Sometimes patients mistakenly think that hospice professionals could take an active role in helping them hasten their death, she says.

"People sometimes confuse passive means of hastening death, like disconnecting someone from life support and withholding medicine, from an active means, but these are two different issues," Arnold says. "Most professional hospice organizations do not support legalization of assisted suicide."

Hospices need to resolve all unmet needs

Arnold's research has found that the most common reasons why hospice patients want to hasten death are having a poor quality of life and a concern about suffering.

Social workers also report that suicidal patients may have a decreased ability to participate in enjoyable life activities, Arnold says.

Social workers and other hospice professionals can help suicidal patients by listening to their concerns, without lending support to the idea of hastening their lives, Arnold suggests. "With patients and family members it's important to give them permission to have that conversation about hastening death," she says. "Just because you're willing to listen doesn't mean you're supportive of it."

This conversation allows the hospice to identify and address any unmet needs, Arnold says. "You could say, 'Tell me why and how you reached this decision to hasten your death, Why is this something you feel like you need to do?'" she says.

The hospice industry should have more conversations about this issue because it can be very stressful for hospice providers who have suicidal patients, Arnold says.

Let the patients voice what they're feeling and experiencing, Arnold suggests.

Listening shows that the hospice professional cares, she says. "A lot of times people consider hastening death because they have things going on that are impacting their quality of life negatively," Arnold says.

Reference

1. Arnold EM, Artin KA, Person JL, et al. Consideration of hastening death among hospice patients and their families. J Pain Symptom Manage 2004; 27:523-552.

Need More Information?

  • Liz Arnold, PhD, Assistant Professor, Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1087. Telephone: (336) 716-4657. E-mail: earnold@wfubmc.edu.
  • Van Grinwis, RN, Home Care Manager, CarePartners Hospice & Palliative Care Services, 63 Sweeten Creek Road, Asheville, NC 28803. Telephone: (828) 255-0231.